Routine inspection·September 16, 2021

LPA Melissa Spaeth, LPA Eleza Jackson and LPM Cassandra Harris conducted an unannounced annual visit to the facility at 10:05 am. Upon approaching the facility, LPAs observed the COVID signs on the door. LPAs and LPM were greeted by caregiver, Restituto (Rusty) Ebora and explained the purpose of the visit. LPA Spaeth observed caregiver was wearing a mask. Caregiver called Administrator Lucia Dela Rea and Administrator arrived to the facility at 10:15 am. LPAs' and LPM's temperature was taken upon entry and recorded. LPA Spaeth observed a thermometer, hand sanitizer, PPE masks, and sign in sheet at the front door. The LPA's and LPM began tour at 10:20 am. LPA Spaeth observed two residents in the family room watching television. LPAs and LPM observed the four resident rooms. All rooms contained the necessary regulation requirements which include lamp, nightstand, chair and other items needed for the comfort of the residents. LPAs observed the three bathrooms contained the required wash your hands sign, hand soap, paper towels, and trash cans in each bathroom. All parties then were escorted to the garage and LPA observed a refrigerator which contained fresh vegetables, frozen meats and vegetables, canned goods, PPE supplies such as face shields, surgical gowns, and gloves. Administrator unlocked a cabinet which contained hygiene items for residents. Upon entering the kitchen, LPA observed an adequate supply of canned goods in the pantry, fresh fruits, fresh vegetables, dairy products in the refrigerator. The frozen section of the refrigerator contained frozen meats and vegetables. LPA Spaeth observed the knives were locked in a kitchen drawer and cleaning supplies were locked under the kitchen sink. At 10:17 am, LPAs and LPM observed the staff room which was not locked. LPAs observed the caregiver was not in the room and saw a bottle of rubbing alcohol and a bottle of medication was sitting in the room. LPAs informed Administrator that the staff room should be locked at all times. The staff room was locked by Caregiver at 10:30 am. At 10:25 am LPAs entered a bathroom which residents will use the toilet and sink when needed. LPA Spaeth tested the water temperature and recorded the temperature was 136.5 F. LPA stated to Administrator the water temperature should be between 105 to 120 degrees F. LPA Spaeth stated to Administrator best practice would be to check the water temperature each week. Administrator stated will make sure the water temperature will be checked each week. Also LPA Spaeth observed the shower did not contain a slip resistant mat. At 2:20 pm Administrator purcahsed non slip mats and added to the bathroom. LPAs and LPM were then escorted to the garage and observed the Caregiver took a key off a nail on the wall to open the garage. Upon entering the garage, LPA observed laundry detergent was not locked within the garage. LPA Spaeth explained the key should be stored in a secure area out of reach of the residents. LPA Spaeth also explained since there are two dementia residents living the facility, the keys need to be stored in a secure location. Administrator then removed the key from the wall. At 10:47 am LPAs and LPM observed the staff and resident files were stored in an unlocked cabinet in the dining room. LPA Spaeth stated to Administrator that all records must be locked and secure. Also, LPAs observed the medication cabinet was not locked. LPA's reminded Administrator medication cabinet should be locked when not in use. At 11: 44 am, LPA Jackson reviewed resident files and observed there were two hospice care plans for R1 and R2. Postural support documentation was missing for R3 through R6. Under Title 22 General Regulations, the following citations were issued and recorded on LIC 809D.